Provider Demographics
NPI:1083613269
Name:LAKE PHYSICIANS AND HOSPITAL SUPPLY
Entity Type:Organization
Organization Name:LAKE PHYSICIANS AND HOSPITAL SUPPLY
Other - Org Name:LAKE SURGICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:TREZZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-627-8100
Mailing Address - Street 1:92 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:DENVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07834-2761
Mailing Address - Country:US
Mailing Address - Phone:973-627-8100
Mailing Address - Fax:973-627-4114
Practice Address - Street 1:92 BROADWAY
Practice Address - Street 2:
Practice Address - City:DENVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07834-2761
Practice Address - Country:US
Practice Address - Phone:973-627-8100
Practice Address - Fax:973-627-4114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ0063901332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2580501Medicaid
NJ2580501Medicaid